Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan.

INTRODUCTION: Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost.
METHODS: We conducted 4 focus groups to understand beneficiaries' experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian.
RESULTS: While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process.
CONCLUSION: Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.

Introduction

To obtain publicly subsidized prescription drug insurance, Medicare beneficiaries must enroll in one of 24 to 33 private plans depending on where they live in the United States (1). Choosing a Medicare Part D plan is difficult as health insurance is a complicated product and many Americans, not just older adults, have a limited understanding of many of the basic features of health plans (2). Studies of Part D plan choices have documented that decision-making quality declines as choice set size increases, particularly among older adults (3 –6). Because drug coverage varies across plans and people’s drug needs differ based on their health status, the plan that provides the best coverage varies across people.

The process of choosing a prescription drug plan is frustrating and confusing for Medicare beneficiaries (7 –10). Research analyzing which plans people choose is consistent with these observations. Some studies have found that while seniors appreciate being able to choose from a variety of plans, they do not feel confident in their ability to do so and want the selection process to be easier (11). People are often not enrolled in the plan that would cover their drugs at the lowest price (12,13) and rarely change plans even when there are alternatives that provide ex ante coverage at a lower cost (14,15).

Previous research has recognized the factors influencing choices and the types of resources people use when selecting a Medicare Part D plan, but it has been based primarily on brief survey questions or individual interviews. Surveys and analyses of claims data have shown that variables affecting plan selection include plan price (ie, premiums) (12,16) and perceived future need for medications (16). One interview study found that some beneficiaries discussed Part D plans with their doctors (15%), yet they were still confused about insurance coverage (4).

Limited qualitative evidence exists, however, on how beneficiaries make prescription drug plan choices, particularly regarding barriers to decision-making, and how older adults respond to those barriers (4,11). A focus group study conducted in 4 cities across the United States found the process to be frustrating due to the volume of information that they received through mail and media (11). However, this study asked participants about both Medicare Advantage and Part D plans. Choosing a Medicare Part D plan may differ from choosing a Medicare Advantage plan as beneficiaries usually choose from many fewer options when choosing a Medicare Advantage plan, and fewer choices may affect how beneficiaries perceive plan selection. Additionally, the focus group participants were from varying education and economic levels; the selection process could potentially be very different among people with different levels of education and financial resources.

We sought to qualitatively understand the experiences of individuals selecting a Part D plan, not including Medicare Advantage, and to identify what resources and which factors were of greatest importance to beneficiaries. Participants were highly educated with significant income illustrating barriers to decision-making even among those who likely have the most resources.

Methods

Participants were patients of Palo Alto Medical Foundation (PAMF), a large, multispecialty health-care delivery system serving over 1 million patients in Northern California. We used the focus group method because of its ability to foster an open dialogue and stimulate ideas from group discussion, to provide the opportunity to ask follow-up questions and clarify answers, and to surface more perspectives in a shorter time period relative to individual interviews (17). The protocol was approved by the institutional review boards at PAMF and Stanford University.

Potential participants were recruited through patient and clinician research partners’ recommendations, flyers posted at and e-mails sent to a local older adult aging-in-place community, promotions at several older adult-focused events, and an article in the PAMF newsletter. During screening, participants were included in the study if they had personally selected a Medicare Part D prescription drug plan and were thereby excluded if they were enrolled in a Medicare Advantage Plan. From a total of 50 patients who provided contact information in response to outreach efforts, we confirmed that 25 met the eligibility criteria. The other 25 were not selected because either they had not yet chosen a Medicare plan (eg, just turned 65) or, for the majority, they were actually enrolled in a Medicare Advantage (health maintenance organization [HMO]) plan rather than a stand-alone Part D plan. Ultimately, 17 people participated in 1 of the 4, 90-minute focus groups between June and early October 2014. All participants provided written informed consent and were compensated $50 USD for participating in the focus group.

The focus groups were moderated by a qualitative medical sociologist who has had previous experience conducting focus groups (18). A semi-structured interview guide asked about the process of choosing a Part D plan and the resources they used to make their decision (Table 1). Participants also completed an exit questionnaire to provide demographic information.

Table 1.

Focus Group Interview Guide for Selecting a Medicare Part D Prescription Drug Plan.

1. How would you describe your experience choosing a plan?

a. How did you go about choosing a Part D prescription drug plan?

b. What were some of the challenges?

c. What was most helpful?

2. Did you look for information before making your decision?

d. What sources of information did you find?

i. Were those sources of information helpful when you made your choice?

ii. Why or why not?

iii. Of the sources you found, which sources did you use to make your decision?

3. Did you use any tools to help you select your plan?

e. For example, when selecting a flight, many people use online tools to search for a flight, such as sites like Travelocity.com and Expedia.com.

4. Did you consult anyone about your decision?

f. Whom did you consult?

g. Did you consult your health-care team to help you make the decision?

5. What types of information would you have wanted to make this decision which you were not able to find?

6. What plan features were important in making your choice?

7. What would you do differently next time you chose a Part D plan?

8. Looking back on your experience, what would your ideal type of help be for choosing a Medicare Part D plan?

Additional questions (if applicable):

– Why did you not switch your plan in the most recent open enrollment period?

– Did you consider changing your plan?

All focus groups were digitally recorded and transcribed verbatim. After completing 4 focus groups, similar comments and themes emerged and we concluded that “thematic saturation” had been achieved—additional data did not reveal new findings but rather reinforced existing conceptual constructions. Based on the study aims, the research team developed an inductive codebook to identify emergent themes from the data, which was modified iteratively based on input from the coders and project team. There were overarching codes developed from the focus group interview guide (Table 1) such as “important characteristic of plan,” and these were further refined into themes such as reputation of the company, convenience of the plan, and able to get medications by mail order. Other themes were added as they emerged, such as a code for “avoiding changing a plan” and making their decision “independent” of others. Transcripts were coded at the paragraph level in Atlas.ti 7.5.3. Researchers discussed disagreements in thematic coding until consensus was reached.

Results

The 17 participants were highly educated and nearly all Caucasian, with nearly two-thirds (64%) reporting incomes above $75 000 USD. The mean participant age was 71 years, nearly two-thirds (65%) were married, and almost all participants were retired (Table 2).

Table 2.

Demographic Characteristics of Participants in Focus Groups Regarding Selecting a Medicare Part D Prescription Drug Plan.a

Characteristic (N = 17)	Mean	%
Age, years	71 (min = 65, max = 91)
Sex
Female		65
Male		35
Marital status
Divorced/separated		23
Married/living as married		65
Widowed		12
Race/ethnicity
Caucasian/white		94
Asian/Pacific Islander		6
Education completed
College		41
Master’s degree or higher		59
Currently employed
No		6
Retired		88
Yes, part time		6
Annual household income
$15 001-$35 000 USD		6
$35 001-$50 000 USD		6
$50 001-$75 000 USD		12
$75 001 USD or more		64
No answer		12

aMedicare Part D focus group exit questionnaire.

Several themes emerged across the 4 focus groups regarding the participants’ experience selecting a Medicare Part D plan, with most expressing challenges and difficulties, which ultimately led them not to want to revisit changing their plan. Additionally, participants reported on the resources that were of greatest value to them including organizations, the Internet, and insurance brokers. Finally, many participants expressed that there were other factors such as reputation of the insurance company, convenience of plan, and uncertainty of medication needs in the future that were also of great importance in selecting a plan along with costs and formulary coverage.

Overview of Experience

Most participants voiced that selecting a plan was a negative experience overall. Several described it as a “nightmare,” being “extremely difficult to navigate,” “extremely frustrating,” “overwhelming,” and “confusing,” furthermore noting that it “didn’t make sense” due to “too many options” and “reams of paperwork to figure out.” One participant recalled that it was “not easy to discern from the results which one [he] should pick.” A few other participants found the difficulty in choosing a Part D plan to be on par with filing their taxes: “It’s like the tax code. You have to almost have an accountant.” Additionally, a participant said, “I mean I think I have more problems with the health care thing than I do with the income tax, which is not easy.” Many expressed that difficulties with plan selection are even greater given aging and that “as we [older adults] need things as we get older to be less confusing” but instead they are just “getting more and more complex and difficult to manage.”

Only a few participants said that they had a good experience in choosing a Medicare Part D plan. One participant said that his plan selection experience was “very good” because he consulted his wife’s coworker who provided medical counseling. Another participant said that she had it “spoon fed” to her by a representative who visited her older adult residence community, the representative “laid it out,” and “boiled down all the facts” into some sheets, which made choosing a plan “so easy.” However, these experiences were exceptions.

Effect of Negative Experience: Avoiding Change

Because of the difficulty and complexity associated with plan selection, participants expressed that after they have made a decision and achieved a general level of satisfaction, there is little incentive to later reevaluate their plan, reasoning that their “plan was good enough, I wasn’t gonna look farther.” Another said “why would I want to do something different when things are going fine with the current plan?” Change only occurred for some participants when they were “dropped” from a previous plan, no longer satisfied with their current plan, they had experienced a significant life change, or faced an increased expense. A resident of an older adult living community described an incident when many community members were no longer covered by one of the drug plans: “Some people panicked because it meant change” and most of them begged “don’t change anything for me.” A friend of hers was described as “courageous” for stepping out of her previous plan. Beyond not wanting to change their plans, many participants reported that previous negative experiences influenced which resources they used and which ones they would seek out in the future.

Resources Used to Make Decision

Many participants reported that they received support from the Health Insurance Counseling and Advocacy Program (HICAP), California’s specific State Health Insurance Assistance Program. Funded by the federal US Department of Health and Human Services, they provide free in-depth, one-on-one insurance counseling and assistance to Medicare beneficiaries, their families and friends, and caregivers. Many participants knew of HICAP and its counseling services, regarding HICAP as a “totally impartial” resource with “no vested interest in any plan.” One participant even joked, “I see [my HICAP counselor] more often than some of my grandchildren.”

Participants also described 2 organizations catering toward the older adult community—a not-for-profit retirement community and an older adult aging-in-place organization—as valuable during the Part D selection process, since they often provided members with supplemental resources that aided in their decision-making. Despite appreciating these resources, participants noted how “they’re understaffed in the [organization’s] office” and repeatedly voiced a desire for these organizations to have somebody who “[would] sit down with them.” Participants almost universally found great value in human-to-human interaction during the plan selection process.

Internet use primarily comprised the websites of Medicare.gov, AARP, Consumer Reports, or specific insurance companies. The most commonly mentioned web destination was the Medicare.gov Plan Finder tool. Participants had either personally used it or had consulted someone else who had used it in for guidance. Although a handful of participants found this tool at least somewhat helpful, others described it as confusing and with website glitches. Opposed to other resources where you “just [look] up information,” with the interactive Plan Finder tool, “essentially, you have to tell it what you wanna do.”

Beyond receiving advice and support, several participants expressed that they needed someone to make the decision for them because there was just too much information for them to navigate the “maze.” As one woman lamented, “[I] just needed a human being to help me and tell me, basically, what do you need.” Family members beyond spouses were only occasionally mentioned because in the words of one participant, “My family knows less about it [Medicare Part D plans] than I do” since “they don’t handle the experience [of] having to use it.” Oftentimes, family members needed to have special qualifications, such as being a physician or an insurance agent, for the participants to seek their counsel.

In an effort to minimize frustration and confusion from the “volumes and volumes of medical information” typically encountered while consulting varied resources, several participants elicited the help of professional brokers who advised them personally on their Part D plan selection and helped them to “figure things out.” One woman said that since she did not know what she was comparing among the different plans, she became “just so sick of looking at it [Part D plans],” so she just took the plan recommended to her by a broker.

Important Plan Characteristics

Although cost and drug formulary coverage were named as important in selecting a Part D plan, many participants said that the decision was more complex with consideration of other factors including the reputation of the insurance company, the convenience of the plan, and fear of future medication needs.

Many participants reported “reputation” of the insurance company as a consideration when selecting for a plan. Reputation, as described, is influenced by whether the company “make[s] mistakes often,” can “handle claims satisfactorily,” or ensures that you “can reach somebody if you need to.” Additionally, participants wanted to know how long the company had been in business as they do not want a “fly-by-night drug company” for they “wouldn’t trust…a company that had been in business just a year,” acknowledging that “[the company] might be really good. But I’d be leery. I want proof.” Information about reputation was gathered from informal sources (ie, friends, family, coworkers) and formal sources (ie, Consumer Reports, AARP). Reputation had a varying influence on the participants’ willingness to enroll in a plan. One participant said that the reputation of the company “means more than anything,” while another participant said that the “annual cost” was her first consideration and her second was the plan’s service and ratings.

Participants frequently noted a plan’s “convenience” as being important, although interpretations of convenience varied. One woman chose a plan in which she did not have “to chase down somebody to…find out about prescriptions.” For another woman, “convenience” meant “less paperwork” and “less research,” as she is “not too literate on the computer” and “phone calls are difficult for [her] because [she] can’t hear everybody.” For her, convenience means “leave me alone.” One participant said that convenience was important because “convenience is not just less paperwork. It’s less worry.” For him, worries that may be lessened included “not meeting a deadline. Not getting something done that has to be done.” Some participants felt that it was more convenient to stay on the same plan as previous years or to select the same plan as a spouse, even if the cost was higher. One participant said that he wanted to be on the same plan as his spouse because it’s “simpler to get the same material” and not have to research other plans.

Several participants reported that plan choice presented them with a conflict between their medication needs in “here and now” and those in the future. Most recognized that they can switch plans after 1 year, yet fear inadequate coverage in case their circumstances change before the next open enrollment: “the other worry is what if I fall down and hit my head? You know, break a leg or get in an automobile accident.” Another participant expanded, “And this is very, very frustrating to me [selecting a plan] because I don’t know what things are gonna pop up because I’ve been fairly healthy. So, occasionally, some kind of an infection will occur, and then I need a medication.”

Given the potential for unforeseen changes in health, some participants gained comfort in having what they deemed “extra protection” built into a plan: “We didn’t sign up for the least expensive because…one or both of us would be taking medications at some point…you don’t know what medications you’re gonna be taking.” Another participant said that he picked a plan in the middle tier of options to fit his “comfort level”: “And so, I picked something in the middle…what looked to me like a reasonable price…and what I thought I could afford.”

Discussion

Similar to the findings of a previous focus group study (11), reputation of the company was very important as some participants “trusted” companies familiar to them, even if another plan had a lower cost. Varying aspects of “convenience” could also override concerns of cost given the desire to keep things simple and easy. Like our study, Jacobson et al also found that participants turned to insurance brokers and suggestions from others to help them select a plan (11).

Although several of our findings were similar to those of Jacobson et al, some key differences existed. Our research focused on Part D plans, rather than both Medicare Advantage and Part D plans, which may affect how beneficiaries perceive plan selection. Another difference was that most of our sample was highly educated. Even these highly educated participants expressed that they were very frustrated and confused by the process, potentially providing insight into previous findings of “elders making choices which are inconsistent with optimization under full information” (12). Several participants reported purposefully choosing a “middle” range plan (as opposed to a cheaper plan) to ensure adequate coverage in the event of a change in health status, similar to a previous study that found beneficiaries “overprotecting themselves by paying higher premiums” (19).

Also consistent with previous research (11,20), we found that participants who perceived the Medicare Part D selection process as “complex” were less likely to consider changing plans. This shows that a benefit to simplifying the process of choosing a plan may be that participants would want to revisit their plan selection more frequently, rather than just sticking with the plan they have to avoid a difficult and frustrating experience. Many of our participants said that previously difficult experiences led them to avoid changing their plan and drove them to seek help from a “live” person, like an HICAP counselor or an insurance broker, to mitigate confusion through a verbal exchange. The HICAP counselors may be the better option of the two—HICAP is publicly funded so counselors likely have no conflict of influence that would steer beneficiaries into a specific health plan, unlike many brokers. However, HICAP counselors are unknown to many beneficiaries and underutilized. It is unclear whether participants were aware of potential differences in incentives between HICAP counselors and brokers who may be affiliated with particular plans. Given some of the reported complexity from using the online Medicare.gov Plan Finder, we suggest that Centers for Medicare and Medicaid Services (CMS) offer a more user-friendly online tool and encourage beneficiaries to contact neutral advisors such as HICAP counselors to help them navigate the Medicare Part D decision-making process.

One of the main limitations of this study is potential selection bias regarding who chose to participate in the focus groups. Another possible limitation is that those participants who harbored views dissenting from those expressed in the focus group may have felt uncomfortable stating their differing opinions. However, this was minimized by the previous experience and skills of the moderator. Furthermore, most participants chose their plan nearly a year before the focus group, so there is possible recall bias. Thus, future studies may consider conducting focus groups immediately after open enrollment. Additionally, research on how other populations make Medicare Part D decisions is necessary to determine whether beneficiary experiences are influenced by characteristics such as education, income, and race/ethnicity.

Conclusion

Participants in our study found it difficult to choose Medicare Part D plans. Our study focused on a small set of older adults with relatively high levels of formal education and financial resources, pointing to difficulty even among those potentially best positioned to make these choices. Our findings suggest that older adults may be reluctant to switch Medicare Part D plans due to the difficulties they face in choosing among plans and that they are concerned about not having sufficient coverage for future unanticipated events. Although Medicare beneficiaries would benefit from greater assistance in choosing among plans, it is likely that differences exist among them in the type of assistance that would be most effective. Future research should focus on the type of tools and assistance that would be most effective for different types of beneficiaries. We suggest that a more simplified web tool and neutral advisors such as HICAP counselors may be helpful for seniors choosing a Medical Part D plan and may encourage more frequent examination of plans.